Transcript COMMON SYMPTOMS

COMMON SYMPTOMS
What do they mean?
ACUTE- < 3 weeks.
PERSISTENT/ CHRONIC- > 3 weeks
CHAPTER 2
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COUGH
ACUTE
 In healthy adults, most cases of acute cough are due to
viral respiratory infections.
 Chronic medical conditions can cause acute cough during
exacerbations: asthma, CHF, allergic rhinitis.
 Cough from a viral respiratory infection CAN persist
beyond 3 weeks.
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COUGH
ACUTE
 Dyspnea does not typically accompany acute cough in a
viral resp infection, and
 Cough + Dyspnea- requires a work-up: CXR, ABGs,
PFTs, Cardiovascular eval.
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COUGH
PERSISTENT
 In the absence of respiratory infections, therapy w/ ACE
inhibitors, or abnormalities on CXR, 90% of cases of
persistent cough are due to:
 1) Postnasal drip (allergies).
 2) Asthma.
 3) GERD.
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COUGH
PERSISTENT
 OTHER CAUSES:
 Lung cancer, TB - both can present w/ fever, night
sweats, weight loss.
 Chronic bronchitis / COPD.
 Other chronic infections (crypto, coccy, etc.)
 Interstitial lung disease- pulmonary fibrosis, sarcoidosis,
etc.
 Psychogenic.
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COUGH
DIAGNOSTIC STUDIES
 ACUTE COUGH- CXR should be done in the patient
with: abnormal vital signs (tachycardia, tachypnea);
physical exam findings suggestive of pneumonia (rales,
consolidation), decreased pulse-ox.
 PERSISTENT COUGH- CXR, empiric Rx for postnasal
drip, GERD, asthma for 2-4 weeks; if no better, PFTs,
referral.
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DYSPNEA
 The perception of uncomfortable breathing.
3 BROAD CATEGORIES:
 1) MECHANICAL- COPD, myasthenia gravis
 2) COMPENSATORY- hypoxemia, acidosis.
 3) PSYCHOGENIC- anxiety / panic attack.
 Dyspnea commonly accompanies a multitude of acute and
chronic medical conditions.
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DYSPNEA
 Acute dyspnea as the chief complaint warrants urgent
evaluation, looking for:
 P.E., pneumothorax, asthma, COPD.
 Pneumonia, cardiac disease such as MI, CHF, valvular
dysfunction (rupture of chordae tendonae), arrhythmias.
 Metabolic acidosis (DKA eg), methemoglobinemia,
carbon monoxide poisoning, cyanide toxicity (such as
from smoke inhalation).
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DYSPNEA
 Can distinguish mechanical from compensatory from
psychogenic with arterial blood gas (ABG) evaluation.
EXCEPT for: cyanide toxicity and carbon monoxide
poisoning.
 MECHANICAL- respiratory acidosis, w/ or w/out
hypoxemia.
 COMPENSATORY- respiratory alkalosis w/ or w/out
hypoxemia or metabolic acidosis.
 PSYCHOGENIC- respiratory alkalosis.
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ACID-BASE REVIEW
CO2 + H20 ↔ H2CO3 ↔ H+ + HCO3‾
(H2CO3 = CARBONIC ACID, HCO3‾ = “BICARB”)
HENDERSON HASSELBACH EQUATION
pH = pKa + log([HCO3‾] / 0.03[CO2])
OR, SIMPLIFIED
pH = -log10(H+)
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ACID-BASE REVIEW
 Remember to consider what is the disease and what is the
compensatory response
 The disease:
 RESPIRATORY ACIDOSIS: CO2 IS RETAINED, pH goes down
 RESPIRATORY ALKALOSIS: CO2 IS EXHALED, pH goes up
 METABOLIC ACIDOSIS: DECREASE IN HCO3, pH goes down
 METABOLIC ALKALOSIS: INCREASE IN HCO3-, pH goes up
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ACID-BASE REVIEW
 The compensation:
 SHORT TERM: respiratory, by altering amount of CO2
exhaled.
 LONG TERM: by the kidney, by altering amount of H+
excreted, thereby changing HCO3-.
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ACID-BASE REVIEW
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For review of Acid-Base Metabolism:
http://www.nda.ox.ac.uk/wfsa/html/u13/u1312_01.htm
http://www.acid-base.com/index.php
For interpretation of ABGs
http://www.health.adelaide.edu.au/paedanaes/javaman/Respiratory/a-b/AcidBase.html
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DYSPNEA –
THE DDx BASED ON Sxs
 If dyspnea is sudden in onset and severe, and absence of other Sxs,
think: P.E., pneumothorax, increased LVEDP (as in CHF, silent MI).
 W/ chest pain, think: M.I., P.E., pneumo, pleurisy, pericarditis.
Need to dig deeper into the pain- was it acute in onset, chronic, pleuritic,
exertional.
 W/ fever and cough think infection.
 Dyspnea w/ no other Sxs, think non-cardiopulmonary causes of
impaired O2 delivery: anemia, carbon monoxide, methemoglobinemia,
PE, metabolic acidosis.
 W/ wheezing, think: asthma, COPD, foreign body.
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DYSPNEA – THE PHYSICAL EXAM
Inspect- breathing pattern, resp rate, pursed lips (emphysema),
barrel chest (chronic bronchitis), use of accessory muscles
(asthma), asymmetrical excursion of the chest and/or diaphragm
(pneumo).
Head & Neck- JVD (CHF).
Lungs- the usual- breath sounds, crackles and wheezes
Heart- the usual- murmurs, rubs, location of PMI, etc.
Extremities- edema (CHF), evidence of DVT (P.E.).
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DYSPNEA – DIAGNOSTIC STUDIES
 “Causes of dyspnea that can be managed without a chest X-ray are few:
ingestions causing lactic acidosis, methemoglobinemia, and carbon
monoxide poisoning.”
 “In the absence of physical examination evidence of COPD
or CHF, the major remaining causes of dyspnea include
P.E., upper airway obstruction, foreign body, and metabolic
acidosis.”
 CXR, ABG’s, EKG.
 V / Q SCAN – to r/o P.E. (Ventilation/Perfusion Scan =V/Q)
 Blood tests- CBC, carboxyhemoglobin & methemoglobin levels.
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EDEMA
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DIFFERENTIAL Dx
CHRONIC VENOUS INSUFFICIENCY.
VENOUS THROMBOSIS.
CELLULITIS.
MUSCULOSKELETAL DISORDERS. (ruptured Baker’s cyst).
LYMPHEDEMA.
SYSTEMIC DISEASE- CHF, cirrhosis, renal failure, nephrotic
syndrome.
MEDICATION- Ca channel blockers.
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EDEMA
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CHRONIC VENOUS INSUFFICIENCY
By far the most common cause of edema.
2% of the population.
Due to incompetence of the valves in the veins of the leg; also a
complication of DVT.
Results in leakage of not only fluid but leukocytes and other
inflammatory components, resulting in lymphatic obstruction and
worsening edema.
PRESSURE IS A DISEASE- ultimately results in impaired arterial
supply, tissue necrosis, ulceration.
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EDEMA
CHRONIC VENOUS INSUFFICIENCY
 PHYSICAL FINDINGS: shiny, atrophic skin, lack of hair,
increased pigmentation; pitting; redness & warmth when
inflamed; stasis ulcer most commonly over the medial
malleolus;
 Can be unilateral or bilateral.
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EDEMA
D.V.T
 The most life-threatening cause of edema.
 Unilateral.
 Risk factors: recent immobilization from surgery; bedrest, air travel; OCP / estrogen use; pregnancy and the
puerperium; obesity; malignancy; less commonly genetic
deficiencies of Protein S, Protein C, or Anti-thrombin III;
Mutant Factor V (the “Leiden” mutation).
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EDEMA
D.V.T
MANIFESTATIONS:
 Pain, swelling, muscle tenderness (calf/gastrocs)
 Many cases of DVT are asymptomatic.
 Most common sites: venous sinuses in the soleus muscle,
and in the posterior tibial and peroneal veins.
 HOMAN’S SIGN: pain in the calf on dorsiflexion of the
foot.
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EDEMA
WHEN EDEMA IS BILATERAL
 THINK SYSTEMIC DISEASE.
 CHF.
 NEHROTIC SYNDROME & CIRRHOSIS, DUE TO
DECREASED INTRAVASCULAR OSMOTIC PRESSURE
FROM HYPOALBUMINEMIA.
 THESE PATIENTS WILL ALSO HAVE THE OTHER
FEATURES OF THOSE CONDITIONS.
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EDEMA
DIAGNOSIS / DIAGNOSTIC STUDIES
 History, physical exam.
 Assess for risk factors for DVT.
 Unilateral or bilateral.
 Other physical findings to suggest systemic disease?
 Color duplex ultrasonography. The “Doppler” study. Use
liberally to R/O DVT as DVT is hard to exclude on
clinical grounds.
 Measure D-dimers of fibrin degradation products in the
serum
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EDEMA
TREATMENT OF VENOUS INSUFFICIENCY
 1) ELEVATION.
 2) COMPRESSION.
 Consider referral to a vascular surgeon, as some
patients w/ chronic venous insufficiency will also
have peripheral artery disease, which can be
worsened with compression.
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FEVER
 Most commonly due to infections.
 In adults: 25-40% infections, 25-40% malignancy.
 In children: infection 30-50% of the time.
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FEVER
FUO - fever of unknown origin –
“unexplained cases of fever exceeding 38.3° C. on several occasions for at
least 3 weeks in patients without neutropenia or immunosuppression.”
CAUSES OF FUO:
1) INFECTION
2) NEOPLASMS
3) AUTOIMMUNE DISORDERS
4) MISCELLANEOUS
5) 10-15% UNDIAGNOSED CAUSES
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FEVER
CAUSES OF FUO
 1) INFECTION- TB, endocarditis, fungi, occult abscesses,
osteomyelitis, UTI, and other “exotic” infections such as
malaria, toxoplasmosis, CMV, etc.
 2) NEOPLASMS- most commonly lymphomas and leukemias.
 3) AUTOIMMUNE DISORDERS- most common are Juvenile RA
(Still’s Disease), Lupus, Polyarteritis Nodosa.
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FEVER
CAUSES OF FUO
 4) MISCELLANEOUS- thyroiditis,
sarcoidosis, recurrent PE, alcoholic
hepatitis, Crohn’s, drug fever, etc.
 5) 10-15% UNDIAGNOSED CAUSES- of these, 75%
will abate without treatment, the rest will
eventually manifest their underlying disease.
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FEVER
EVALUATION
 “Uncommon presentations of common diseases
are more common than common presentations
of uncommon diseases.”
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So look for the common stuff, most commonly infection.
History & physical. Lab as appropriate.
Ask about travel, diet, drugs.
For FUO, I would refer the patient to an internal medicine
specialist, who may refer the patient to an infectious disease
specialist, who may refer the patient to a rheumatologist, who
may……
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INVOLUNTARY
WEIGHT LOSS
 Loss of 5% or more of usual body weight over 6-12 months.
 Often indicates serious physical or psychological illness.
 MOST COMMON CAUSES:
1) CANCER- 30%
2) GI DISORDERS- 15%
3) DEMENTIA, DEPRESSION, ANOREXIA- 15%.
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INVOLUNTARY
WEIGHT LOSS
THE WORK-UP
 History and physical. Psychological eval.
 LAB- CBC, Chem profile, TSH, UA, Hemoccult.
 RADIOGRAPHS- CXR, UGI.
 These usually reveal the cause.
 If not, Phase II- GI endoscopy, tests for malabsorption,
Mammogram, PSA.
 In 15-25%, no cause is found. F/U req.
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FATIGUE
1-3% of visits to generalists.
 “Fatigue of unknown cause or related to
psychiatric illness exceeds that due to physical
illness, injury, medications, drugs, or alcohol.”
My take on “unknown cause” is it’s due to an interplay of
life-style and emotional factors.
IMPORTANT CAUSES: thyroid disease, CHF, infection
(endocarditis, hepatitis), COPD, sleep apnea, anemia,
autoimmune disease, cancer.
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FATIGUE
 OTHER CAUSES:
 Alcoholism, recreational drugs, side effects from
medication (sedatives, beta blockers).
 PSYCHOLOGICAL- depression, insomnia, somatization
disorders.
 PSYCHIATRIC- depression, dysthymia, somatoform
disorders, anxiety disorders, panic attack.
 Irritable bowel syndrome.
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CHRONIC FATIGUE SYNDROME
Diagnosis of exclusion.
No confirmatory physical finding or lab tests.
Etiology unknown, no single pathogenic mechanism, likely a
heterogeneous abnormality.
There is a greater prevalence of past and current psychiatric
diagnoses in patients w/ this syndrome, esp. affective
disorders.
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CHRONIC FATIGUE SYNDROME
DIAGNOSTIC CRITERIA
 Work-up/lab is/are normal/negative.
 Criteria for severity of fatigue are met.
 4 or more of the following are present for > 6 months:
1. Impaired memory or concentration.
2. Sore throat.
3. Tender cervical or axillary lymph nodes.
4. Muscle pain.
5. Multijoint pain.- Unrefreshing sleep.
6. New headaches.- Postexertional
malaise.
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CHRONIC FATIGUE SYNDROME
THE WORK-UP
1) History and physical.
2) Mental status exam.
3) Lab- CBC, Chem profile, ESR, TSH, UA.
4) Other tests as indicated by the Hx and PE.
5) Possibly- HIV; ANA, Rheumatoid factor, if joint
symptoms present.
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CHRONIC FATIGUE SYNDROME
TREATMENT
No single drug helpful. No cure, but recovery is possible.
Comprehensive, multidimensional approach.
Current treatment of choice: Cognitive-behavioral
therapy combined with graded exercise.
Sympathetic ear.
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DYSURIA
 Painful urination.
 Common. Common. Common.
DIFFERENTIAL Dx
 Acute cystitis – Dx’d 50-60% of the time.
 Acute pyelonephritis.
 Vaginitis (Candida, trichomonas).
See next slide.
 Urethritis. Cervicitis.
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DYSURIA
SYMPTOMS AND THE Dx
 Dysuria, frequency, urgency WITHOUT vaginal
discharge or itching → increased likelihood of
cystitis.
 Dysuria, frequency, urgency WITH vaginal discharge
or itching → decreased likelihood of cystitis.
 W/ fever, back/flank pain, N/V → think pyelo.
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DYSURIA
SYMPTOMS AND THE Dx
 If the patient has dysuria, frequency, and urgency, w/out
vaginal discharge, itching, fever, or flank pain, you can treat
for cystitis w/ out a fancy-schmancy evaluation or even a UA.
 If any of the other Sxs are present, need to evaluate w/ PE
including vaginal exam, wet prep, KOH, UA.
 Always need to R/O upper tract infection / pyelo as this can
progress to sepsis and septic shock, esp in the older patient.
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DYSURIA
SYMPTOMS AND THE Dx
HEMATURIA
 Can be consistent w/ the Dx of cystitis (hemorrhagic cystitis),
but need to also consider urolithiasis and malignancy
 If upper tract disease is suspected, especially stones, consider
imaging studies- IVP, ultrasound, helical CT.
 Remember: children and the elderly do not always have
“typical” presentations, esp fever in the elderly.
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DYSURIA
TREATMENT
 Acute, uncomplicated cystitis in the otherwise healthy
patient (not immunosuppressed, not pregnant, etc) can
be treated by a 1-3 day course of antibioticsmacrodantin, trim-sulfa.
 Phenazopyridine- an OTC drug for symptomatic relief.
 If fever, tachycardia, and hypotension are present,
hospitalization should be considered.
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RED FLAGS
 Hemoptyis
 Hematemesis
 Central chest pain lasting >20 mins
 Shock
 Convulsions
 Headaches requiring emergent neuro-imaging
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